Performance assessment of Emergency Surgical Officers at health facilities in Ethiopia
Ethiopian society of Obstetricians and Gynaecologists (ESOG) led and fully supported an assessment of the services provided by IESOs as part of its objective to support and promote quality reproductive health services in the country. It believes that the findings of this assessment will be highly useful to reflect on and improve the IESO programme of the country. The findings ultimately will help improve the quality of C-EmONC and Emergency Surgical Services provided in health facilities where ESOs are deployed.
- Background and rationale
- Materials and methods
- Conclusions and recommendations
Background and rationale
Ethiopia was committed to the attainment of the Millennium Development Goals (MDGs) by 2015. These included the MDG 4 and 5 aiming to reduce child mortality by two thirds and maternal mortality by three quarters by 2015 from the 1990 levels. To achieve these targets, the government with its partners has been intensifying its efforts to strengthen health care services planning to construct many hospitals and train adequate skilled clinical staff that can provide comprehensive emergency obstetric & newborn care (CEmONC) services as well as emergency surgical services. One of the major initiatives designed by the F-MOH in 2009 was Integrated Emergency Surgical Officers (IESO) initiative which is a Master of Science (MsC) training program. The goal of the MSc training programme is to produce competent Emergency Surgical Officers (ESO) capable to handle common emergency obstetric-gynaecological and emergency general surgical procedures including trauma where a gynaecologist and a surgeon are inaccessible.
ESOs are deployed in several health facilities in different regions of the country since 2012 to provide CEmONC and emergency surgical services. As the deployment of ESOs at health facilities to provide these services is a new experience in the country, conducting the program assessment is reasonable and of paramount importance. In addition, it is to comply with the WHO and global recommendation of careful monitoring of task shifting approaches in health care service delivery like the IESO program.
The general objective of the assessment is to provide an in-depth facility level performance assessment of CEmONC and emergency surgical services provided by emergency surgical officers and inform the different stakeholders for quality improvement of the service provided and the IESO program.
Materials and methods
This is a facility based descriptive cross-sectional assessment. It was conducted by ESOG in collaboration with the Federal Ministry of Health, CDC-Ethiopia, Regional Health Offices, target facilities and other stakeholders. The inclusion criterion was all facilities where ESO’s have been deployed for at least one year before the assessment.
Data was collected in two rounds between July and December, 2015. Data was collected using a data collection format prepared for the purpose by the F-MOH through interviews, discussions with facility staff, a review of patient’s medical records & registers. To facilitate the data collection process and avoid the critical shortage of high level health care providers required for the data collection; the target regions were grouped in to four groups based on geographic proximity and data was collected in four rounds.
The data collector teams conducted the data collection with site visit staying at each facility for 3 - 5 days. All the collected data were coded. Both individual and facility level data were then entered, cleaned and analyzed using SPSS Version 20.0 statistical software. Ethical clearance was obtained from Ethiopian Public Health Institute (EPHI) and Centres for Disease Control (CDC) before data collection.
Data was collected from a total of 96 facilities from 8 regions of the country. About two third of the facilities, 66% (63/96), were primary hospitals. A total of 205 ESOs were deployed and practicing in the facilities with an average of about two ESOs per facility. In the majority of the facilities, 58.3% (56/96), ESOs were practicing in facilities where neither Obstetricians nor Surgeons were deployed (ESO-Only facilities).
Majority, 65.6% (63/96), of the facilities were providing regularly all the 9 signal functions in the 12 months period prior to the facility visit. Two of the facilities never started providing major surgical services although the ESOs were deployed for more than one year prior to the visit. Blood transfusion was the commonest essential service not provided regularly. It was not provided regularly in 32% (18/56) and 12.5% (5/40) of ESO-Only and ESO-Plus facilities respectively.
The volume of MNH and emergency surgical services showed remarkable increment in the year after the deployment of ESOs. The total number of deliveries increased by 40 % compared to the year before ESOs deployment. The increase in the number of deliveries in ESO-only facilities was about twice that of ESO-Plus facilities with 61% and 30% increases respectively. The number of instrument assisted and caesarean deliveries also increased by 39% and 59% respectively. Non-emergency surgical procedures increased by 162% in ESO-Only facilities raising a concern for patient safety and quality of care as ESOs scope of work doesn’t include major elective surgical procedures.
The proportion of intra-facility maternal deaths per total deliveries in the facilities decreased by 38.2% in the year after ESOs deployment. The decrease in ESO-plus facilities (39.1%) was higher than that of ESO-Only facilities (29.7%). There was similarly a remarkable reduction in proportion of early neonatal deaths in ESO only facilities (34.2%) as compared to ESO plus facilities (6.9%).
Excessive blood loss and deep incision extension were the commonest documented complications in cases being managed by the ESOs in both groups of facilities with proportions of 35.6% (48/135) and 20.7% (28/135) respectively.
A total of 170 maternal deaths from the 63 facilities (32 ESO-Only & 31 ESO-Plus) were reviewed. Hypovolemic shock secondary to excessive bleeding was the commonest stated cause of maternal deaths being responsible for 58.5% (79/135) of the deaths. Patient delay to reach the facility was the major contributor for the maternal death in majority, 63.8% (83/130), of cases in both groups of facilities.
The pattern of change for volume of emergency surgical services provided in the facilities was mostly similar to that of MNH services. Shortage of equipments and supplies required for surgery was the commonest challenge reported by 37.6% (53/141) of the ESOs. And, “absence or unsatisfactory duty payment and incentive” was the second commonest challenge reported by 35.5% (33/141). Majority of the ESOs, 68.7% (92/134), expressed their intent to continue working in their current facilities in the year after.
Conclusions and recommendations
Generally the deployment of ESOs in all health facilities (Primary and General Hospitals) has resulted in remarkable increase in volume of MNH and emergency surgical services with improvement in maternal and perinatal outcomes.
Key conclusions and recommendations include:
Shortage of equipment and supplies related to surgery, and absence or unsatisfactory duty payment and incentives were the main challenges reported by the ESOs.
Recommendations: The main challenges reported by the ESOs should be discussed and addressed by the stake holders and respective facilities so as to maintain the achievement gained so far.
Pre-deployment assessment and filling of identified gaps was not done in many of the facilities. The deployment of ESOs in all facilities has led to significant increase in volume of MNH and emergency surgical services compared to the year prior to their deployment. The increase in ESO only facilities especially was more significant compared to ESO plus facilities which is commendable.
Recommendations: Pre-deployment assessment of all facilities need to be done at all times to optimally utilize and maintain ESOs’ clinical skills.
The reduction in proportion of intra-facility maternal deaths by more than a third was a good achievement. Excessive blood loss and deep incision extension were the commonest documented complications in cases being managed by the ESOs.
Recommendations: To further reduce proportion of intra-facility maternal deaths and improve maternal and perinatal outcomes, factors leading to delay in reaching the facilities need to be assessed and addressed accordingly. As the most common complications are excessive blood loss, deep incision extension and wound infection, focused surgical skill building support/mentoring should be considered by the stake holders of the IESO programme.